Provider First Line Business Practice Location Address:
73847 HIGHWAY 111
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALM DESERT
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92260-4005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-346-1113
Provider Business Practice Location Address Fax Number:
760-346-8725
Provider Enumeration Date:
11/15/2006